Provider Demographics
NPI:1013248624
Name:LEWIS, KEISHA (DT)
Entity Type:Individual
Prefix:MRS
First Name:KEISHA
Middle Name:
Last Name:LEWIS
Suffix:
Gender:F
Credentials:DT
Other - Prefix:
Other - First Name:KEISHA
Other - Middle Name:
Other - Last Name:HENRY ROGERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DT
Mailing Address - Street 1:834 W 111TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60643-3839
Mailing Address - Country:US
Mailing Address - Phone:773-568-0743
Mailing Address - Fax:773-568-0743
Practice Address - Street 1:834 W 111TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60643-3839
Practice Address - Country:US
Practice Address - Phone:773-568-0743
Practice Address - Fax:773-568-0743
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-21
Last Update Date:2010-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist